Key points

Office preparedness for an emergency requires an office self-assessment, consisting of a review of personnel and skills, equipment, supplies, medications, and emergency medical services response; practice using mock codes or skill drills; and disaster planning.

A 15-month-old boy with a fever is in the office waiting room when he begins to have a seizure. A 3-year-old girl brought to the office for breathing problems is cyanotic and very lethargic. A patient with multiple medical problems is on vacation when he gets sick and is taken to a local hospital, where the emergency department needs to know some of his medical history. These scenarios are not uncommon for a pediatrician.

Important questions are whether the pediatrician and office staff are prepared; whether the office has the personnel with skills, appropriate equipment, medications, and emergency protocols to handle these problems until emergency medical services (EMS) arrive and are the capabilities of these services known; whether the patients with special health care needs carry an emergency information form (EIF) with them; and what happens when a disaster strikes the surrounding community.

This article reviews methods to optimize readiness for pediatric emergencies in the office setting, provides information about the EIF, and provides some insight into office preparedness for disasters.

Numerous surveys of offices have been conducted on local and national levels to assess pediatric preparedness. Most of these studies showed that pediatricians do see emergencies in the office, or children that require transfer to an emergency department, or hospitalization, especially those with asthma and respiratory difficulties. The good news is that more offices are now equipped with basic equipment, increasing from 42% of offices with oxygen and 35% with bag-valve masks in 1985 to 98% with oxygen and 96% with bag-valve masks in 2011.

In 2007, the American Academy of Pediatrics (AAP) Committee on Pediatric Emergency Medicine developed a policy statement on Preparation for Emergencies in the Offices of Pediatricians and Pediatric Primary Care Providers. This document provides a wonderful framework to review one’s own office preparedness, and will be used, along with other references to help pediatricians adjust their current plan or develop one for their office.

Office self-assessment

One of the first steps in preparing for emergencies is to look at the office practice. What types of patients are seen (eg, newborns through adolescents)? Does the office care for children with chronic medical problems, children with special health care needs, and those who are technology-assisted (eg, ventilator-dependent, tracheostomies)? What emergencies are encountered in the office, and how often? The staffing patterns in the office should be considered: who opens the office and when do patients begin to arrive; whether a nurse or physician is always there, what happens at lunchtime, and what is the weekend staffing situation; whether the office is free-standing, part of a large multispecialty group, or hospital-based.

Further considerations are how far the office is from the local hospital, the nearest children’s hospital with a pediatric intensive care unit, or the closest trauma center; whether contacting the EMS as easy as dialing 911 or does a private company need to be called, and is this number handy; what is the response time of these services to the office; what is their skill level: EMT or EMT-P (paramedic); do they provide a basic or an advanced life support ambulance; what medication can they provide en route; what pediatric equipment they carry; and will they bypass the local hospital and transport the patient to a children’s hospital/medical home if not too far away.

Office self-assessment

One of the first steps in preparing for emergencies is to look at the office practice. What types of patients are seen (eg, newborns through adolescents)? Does the office care for children with chronic medical problems, children with special health care needs, and those who are technology-assisted (eg, ventilator-dependent, tracheostomies)? What emergencies are encountered in the office, and how often? The staffing patterns in the office should be considered: who opens the office and when do patients begin to arrive; whether a nurse or physician is always there, what happens at lunchtime, and what is the weekend staffing situation; whether the office is free-standing, part of a large multispecialty group, or hospital-based.

Further considerations are how far the office is from the local hospital, the nearest children’s hospital with a pediatric intensive care unit, or the closest trauma center; whether contacting the EMS as easy as dialing 911 or does a private company need to be called, and is this number handy; what is the response time of these services to the office; what is their skill level: EMT or EMT-P (paramedic); do they provide a basic or an advanced life support ambulance; what medication can they provide en route; what pediatric equipment they carry; and will they bypass the local hospital and transport the patient to a children’s hospital/medical home if not too far away.

Office personnel and skills

Factors to consider with regard to office personnel and skill are: who greets parents and children entering the office; whether this individual trained is to recognize a child in distress; whether the office has a quick assist/help button or does the staff have to go find someone; and, once a child is signed in, whether someone checks the waiting room to assure that the symptoms are not worsening if there will be delay in that child being seen.

Other considerations are whether the office staff include registered nurses, nurses’ aides, medical assistants, and nurse practitioners. Each of these individuals is part of the “response team,” and therefore their knowledge and capabilities must be understood so that appropriate roles can be assigned. Pediatricians should consider their own capabilities, such as when they last intubated a child, when they last inserted an intravenous or intraosseous line. All of these factors will play into what a pediatrician and the office staff can and should do in an emergency.

Education and training of staff can go a long way to improving an office’s readiness. A simple list of worrisome signs and symptoms may help the person checking in patients understand when to alert a nurse or physician that someone in the waiting room needs immediate attention. Complaints or findings such as wheezing, stridor, cyanosis, seizures, altered mental status, or lethargy should prompt a help/assist call.

Education of the entire staff, at a minimum, should include basic life support training, such as first aid/cardiopulmonary resuscitation (CPR)/automated external defibrillator (AED) training, which includes techniques used in CPR, such as chest compressions, rescue breathing, use of an AED, and foreign body airway maneuvers. This training can be accomplished through the American Red Cross or American Heart Association (AHA). Another option is Pediatric Emergency Assessment, Recognition, and Stabilization (PEARS) offered by the AHA and AAP, which covers additional topics such as recognition of respiratory distress and failure, shock, cardiac arrest, the team approach to resuscitation, and additional skills based on an individual’s level of training. Education of nursing staff can include providing them time to take courses such as Pediatric Advanced Life Support (PALS) and PEARS from the AAP and AHA, Emergency Nursing Pediatric Course from the Emergency Nurses Association, or Advanced Pediatric Life Support from the AAP and American College of Emergency Physicians (ACEP), which all provide education and skills reviews. These courses also provide continuing medical/nursing education, which is required in most states for physicians, and is now required in many states for nurses. The important issue is that although these course do provide instruction and practice time in skills, none provides true competency in the skills taught, such as bag-mask ventilation, intubation, or intraosseous insertion, and therefore frequent “skill days” may be appropriate if the staff is expected to maintain these skills. Another excellent way to practice these skills and prepare for emergencies is through performing mock codes or drills in the office.

A specific plan, including who responds to the quick assist/help call from the receptionist, where the patient should go (eg, is there a larger room in the office that would allow more equipment and people than a standard examination room), and what everyone’s roles are, must be defined beforehand. This plan should also be tailored to when staffing is at a minimum. Roles on the response team can include who will provide airway assistance/oxygen and bag-mask ventilation if needed; who will get vital signs and begin to chart; who will get intravenous/intraosseous access (if needed); who will get, prepare, and administer medications (if needed); who will do chest compressions (if needed); who will run the response (team leader); who will get the medical history from the parents and keep them informed; who will document any actions, drugs given, and response; and who will contact EMS.

Documentation of the event is a critical part of the true event or mock code/drill. It provides EMS with information on transfer; a review of the response can provide the office staff with education about what went right or wrong and how to improve the response if a similar situation occurs again; and it also obviously represents legal documentation.